Chapter 39: Pediatric Variations of Nursing Interventions NCLEX

Tepid water or sponge baths are indicated for hyperthermia in children. The nurse should: a. Add isopropyl alcohol to the water. b. Direct a fan on the child in the bath. c. Stop the bath if the child begins to chill. d. Continue the bath for 5 minutes.

A (Add isopropyl alcohol to the water.)

Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is to: a. Allow her to wear her underpants. b. Discuss with her mother why this is important to Katie. c. Ask her mother to explain to her why she cannot wear them. d. Explain in a kind, matter-of-fact manner that this is hospital policy.

A (Allow her to wear her underpants.)

The nurse gives an injection in a patient's room. What should the nurse do with the needle for disposal? a. Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room. b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of patient's room. c. Cap needle immediately after giving injection and dispose of in proper container. d. Cap needle, break from syringe, and dispose of in proper container.

A (Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room. All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container located near the site of use. Consequently, these containers should be installed in the patient's room.)

A 10-year-old female child requires daily medications for a chronic illness. Her mother tells the nurse that she is always nagging her to take her medicine before school. What is the MOST appropriate nursing action to promote the child's compliance? A. Establishing a contract with her, including reward B. Suggesting time-outs when she forgets her medicine C. Discussing with her mother the damaging effects of nagging D. Asking the child to bring her medicine containers to each appointment so they can be counted

A (Establishing a contract with her, including rewards.)

Using knowledge of child development, which of the following is the best approach when preparing a toddler for a procedure? a. Avoid asking the child to make choices. b. Demonstrate the procedure on a doll. c. Plan for teaching session to last about 20 minutes. d. Show necessary equipment without allowing child to handle it.

B (Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child's favorite doll because the toddler may think the doll is really "feeling" the procedure.)

The nurse is planning how to best prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include: a. Planning for a short teaching session of about 30 minutes. b. Telling the child that procedures are never a form of punishment. c. Keeping equipment out of the child's view. d. Using correct scientific and medical terminology in explanations.

B (Telling the child that procedures are never a form of punishment.)

The nurse is caring for an unconscious child. Skin care should include which of the following? a. Avoid use of pressure reduction on bed. b. Massage reddened bony prominences to prevent deep tissue damage. c. Use draw sheet to move child in bed to reduce friction and shearing injuries. d. Avoid rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

C (A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing injuries. Do not drag the child from under the arms.)

The nurse is doing a prehospitalization orientation for a 7-year-old child who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is: a. Unnecessary. b. The surgeon's responsibility. c. Too stressful for a young child. d. An appropriate part of the child's preparation.

D (An appropriate part of the child's preparation.)

It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible can cause: a. Hyperthermia. b. Electrocution. c. Pressure necrosis. d. Burns under sensors.

D (Burns under sensors. It is important to make certain that sensor connectors and oximeters are compatible. Wiring that is incompatible can generate considerable heat at the tip of the sensor, causing second- and third-degree burns under the sensor.)

Kimberly, age 3 years, has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102° F even though she had acetaminophen 2 hours ago. The nurse's action should be based on which of the following? a. Fevers such as this are common with viral illnesses. b. Seizures are common in children when antipyretics are ineffective. c. Fever over 102° F indicates greater severity of illness. d. Fever over 102° F indicates a probable bacterial infection.

A (Fevers such as this are common with viral illnesses. Most fevers are of brief duration, with limited consequences, and are viral.)

Kimberly, age 3 years, has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102° F even though Kimberly had acetaminophen 2 hours ago. The nurse's action should be based on knowing that: a. Fevers such as this are common with viral illnesses. b. Seizures are common in children when antipyretics are ineffective. c. Fever over 102° F indicates greater severity of illness. d. Fever over 102° F indicates a probable bacterial infection.

A (Fevers such as this are common with viral illnesses.)

The nurse is teaching a mother how to perform chest physiotherapy and postural drainage on her 3-year-old child, who has cystic fibrosis. To enable the mother to perform percussion, the nurse should instruct her to: a. Cover the skin with a shirt or gown before percussing. b. Strike the chest wall with a flat-hand position. c. Percuss over the entire trunk anteriorly and posteriorly. d. Percuss before positioning for postural drainage.

A (For postural drainage and percussion, the child should be dressed in a light shirt to protect the skin and placed in the appropriate postural drainage positions. The chest wall is struck with a cupped-hand, not a flat-hand, position. The procedure should be done over the rib cage only. Positioning precedes the percussion.)

The nurse observes erythema, pain, and edema at a child's intravenous (IV) site with streaking along the vein. What should the nurse do FIRST? A. Immediately stop the infusion. B. Check for a good blood return. C. Ask another nurse to check the IV site. D. Increase the IV drip for 1 minute and recheck.

A (Immediately stop the infusion.)

When teaching a mother how to administer eyedrops, where should the nurse tell her to place them? a. In the conjunctival sac that is formed when the lower lid is pulled down b. Carefully under the upper eyelid while it is gently pulled upward c. On the sclera while the child looks to the side d. Anywhere as long as drops contact the eye's surface

A (In the conjunctival sac that is formed when the lower lid is pulled down. The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area.)

Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is which of the following? a. Allow her to wear her underpants. b. Discuss with her mother why this is important to Katie. c. Ask her mother to explain to her why she cannot wear them. d. Explain in a kind, matter-of-fact manner that this is hospital policy.

A (It is appropriate for the child to leave her underpants on. This allows her some measure of control in this procedure, foot surgery.)

A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). The nurse should explain that antipyretics: a. May cause malignant hyperthermia. b. May cause febrile seizures. c. Are of no value in treating hyperthermia. d. Are of limited value in treating hyperthermia.

A (May cause malignant hyperthermia.)

A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, the nurse's best action is to: a. Prepare child for conscious sedation during the test. b. Set up a tray with equipment the same size as for adults. c. Reassure the parents that the test is simple, painless, and risk free. d. Apply EMLA to puncture site 15 minutes before procedure.

A (Prepare child for conscious sedation during the test. Because of the urgency of the child's condition, conscious sedation should be used for the procedure.)

A 7-year-old female child has a fever associated with a viral illness. She is being cared for at home. The nurse should recognize that the principal reason for treating fever in this child is: A. Relief of discomfort. B. Reassurance that illness is temporary. C. Prevention of secondary bacterial infection. D. Prevention of life-threatening complications.

A (Relief of discomfort.)

Mark, age 6 years, is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his "regular diet" trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which of the following is the best nursing action? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at end of every meal that he eats.

A (Request these favorite foods for him. Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, favorite foods should be requested for the child.)

A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his "regular diet" trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at the end of every meal that he eats.

A (Request these favorite foods for him.)

The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse she wants her mother with her "like before." The most appropriate nursing action is which of the following? a. Grant her request. b. Explain why this is not possible. c. Identify an appropriate substitute for her mother. d. Offer to provide support to her during the procedure.

A (The parent's preferences for assisting, observing, or waiting outside the room should be assessed, along with the child's preference for parental presence. The child's choice should be respected.)

The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse that she wants her mother with her "like before." The most appropriate nursing action is to: a. Grant her request. b. Explain why this is not possible. c. Identify an appropriate substitute for her mother. d. Offer to provide support to her during the procedure.

A (The parents' preferences for assisting, observing, or waiting outside the room should be assessed, as well as the child's preference for parental presence. The child's choice should be respected. If the mother and child are agreeable, the mother is welcome to stay. An appropriate substitute for the mother is necessary only if the mother does not wish to stay. Support is offered to the child regardless of parental presence.)

What is critical information for the nurse to incorporate into her care when using restraints on a child? a. Use the least restrictive type of restraint. b. Tie knots securely so they cannot be untied easily. c. Secure the ties to the mattress or side rails. d. Remove restraints every 4 hours to assess skin.

A (Use the least restrictive type of restraint.)

The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should: a. Wash hands thoroughly. b. Check the gloves for leaks. c. Rinse gloves in disinfectant solution. d. Apply new gloves before touching the next patient.

A (Wash hands thoroughly. When gloves are worn, the hands are washed thoroughly after removing the gloves because both latex and vinyl gloves fail to provide complete protection.)

The best explanation for why pulse oximetry is used on young children is that it: A. Is noninvasive. B. Is better than capnography. C. Is more accurate than arterial blood gases. D. Provides intermittent measurements of O2.

A (Is noninvasive.)

When caring for a child with an intravenous (IV) infusion, the most appropriate nursing interventions are to (Select all that apply.) A. Use an infusion pump with a microdropper to ensure the prescribed infusion rate. B. Check IV fluids and infusion rate with another licensed professional. C. Avoid restraining the child to prevent undue emotional stress. D. Observe the insertion site frequently for signs of infiltration. E. Change the insertion site every 24 hours.

A, B, D (Use an infusion pump with a microdropper to ensure the prescribed infusion rate. Check IV fluids and infusion rate with another licensed professional. Observe the insertion site frequently for signs of infiltration.)

The advantages of the ventrogluteal muscle as an injection site in young children include which of the following (Select all that apply)? a. Less painful than vastus lateralis b. Free of important nerves and vascular structures c. Cannot be used when child reaches a weight of 20 pounds d. Increased subcutaneous fat, which increases drug absorption e. Easily identified by major landmarks

A, B, E (Less painful than vastus lateralis Free of important nerves and vascular structures Easily identified by major landmarks These are advantages of the ventrogluteal. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing.)

A nurse is caring for a child in Droplet Precautions. Which instructions should the nurse give to the unlicensed assistive personnel caring for this child (Select all that apply)? a. Wear gloves when entering the room. b. Wear an isolation gown when entering the room. c. Place the child in a special air handling and ventilation room. d. A mask should be worn only when holding the child. e. Wash your hands upon exiting the room.

A, B, E (Wear gloves when entering the room. Wear an isolation gown when entering the room. Wash your hands upon exiting the room.)

Informed consent is valid when: (Select all that apply.) A. Universal consent is used. B. It is completed only for major surgery. C. A person is over the age of majority and competent. D. Information is provided to make an intelligent decision. E. The choice exercised is free of force, fraud, duress, or coercion.

A, D, E (A person is over the age of majority and competent. Information is provided to make an intelligent decision. The choice exercised is free of force, fraud, duress, or coercion.)

It is time to give a 3-year-old boy his medication. Which approach is MOST likely to receive a positive response? A. "It's time for your medication now. Would you like water or apple juice afterward?" B. "Wouldn't you like to take your medicine?" C. "You must take your medicine, because the doctor says it will make you better." D. "See how nicely this boy took his medicine? Now take yours."

A. ("It's time for your medication now. Would you like water or apple juice afterward?")

What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture? a. "You must hold still or I'll have someone hold you down. This is not going to hurt." b. "This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less." c. "Be a big boy and hold still. This will be over in just a second." d. "I'm sending your mother out so she won't be scared. You are big, so hold still and this will be over soon."

B ("This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less.")

A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 mL/8 hr is being infused rather than the ordered amount of 300 mL/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours? a. 200 mL c. 350 mL b. 300 mL d. 400 mL

B (300 mL The TPN infusion rate should not be increased or decreased without the practitioner being informed because alterations in rate can cause hyperglycemia or hypoglycemia.)

When is bronchial (postural) drainage generally performed? A. Immediately before all aerosol therapy B. Before meals and at bedtime C. Immediately on arising and at bedtime D. Thirty minutes after meals and at bedtime

B (Before meals and at bedtime,)

Which information should the nurse include in teaching parents how to care for a child's gastrostomy tube at home? a. Never turn the gastrostomy button. b. Clean around the insertion site daily with soap and water. c. Expect some leakage around the button. d. Remove the tube for cleaning once a week.

B (Clean around the insertion site daily with soap and water.)

Using knowledge of child development, the best approach when preparing a toddler for a procedure is to: a. Avoid asking the child to make choices. b. Demonstrate the procedure on a doll. c. Plan for the teaching session to last about 20 minutes. d. Show necessary equipment without allowing child to handle it.

B (Demonstrate the procedure on a doll.)

The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include which of the following? a. Plan for a short teaching session of about 30 minutes. b. Tell the child that procedures are never a form of punishment. c. Keep equipment out of the child's view. d. Use correct scientific and medical terminology in explanations.

B (Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment.)

A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. What best explains why an intraosseous infusion is started? a. It is less painful for small children. b. Rapid venous access is not possible. c. Antibiotics must be started immediately. d. Long-term central venous access is not possible.

B (In situations in which rapid establishment of systemic access is vital and venous access is hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe lifesaving alternative. The procedure is painful, and local anesthesia and systemic analgesia are given. Antibiotics could be given when vascular access is obtained. Long-term central venous access is time consuming, and intraosseous infusion is used in an emergency situation.)

An important nursing consideration when performing a bladder catheterization on a young boy is to: a. Use clean technique, not Standard Precautions. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

B (Insert 2% lidocaine lubricant into the urethra. The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparation of the child and parents, by selection of the correct catheter, and by appropriate technique of insertion. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure.)

Guidelines for intramuscular administration of medication in school-age children include to: a. Inject medication as rapidly as possible. b. Insert the needle quickly, using a dartlike motion. c. Penetrate the skin immediately after cleansing the site, before skin has dried. d. Have the child stand, if possible, and if he or she is cooperative.

B (Insert the needle quickly, using a dartlike motion. The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated.)

The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the nurse do next? a. Keep arm extended while applying a bandage to the site. b. Keep arm extended, and apply pressure to the site for a few minutes. c. Apply a bandage to the site, and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several minutes.

B (Keep arm extended, and apply pressure to the site for a few minutes. Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation.)

Which nursing action is the most appropriate when applying a face mask to a child for oxygen therapy? a. Set the oxygen flow rate at less than 6 L/min. b. Make sure the mask fits properly. c. Keep the child warm. d. Remove the mask for 5 minutes every hour.

B (Make sure the mask fits properly.)

A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. The nurse should recognize that this: a. Is unsafe. b. May help the child relax. c. Is against hospital policy. d. Is unnecessary because of the child's age.

B (May help the child relax. The mother's preference for assisting, observing, or waiting outside the room should be assessed along with the child's preference for parental presence. The child's choice should be respected. This will most likely help the child through the procedure.)

In preparing to give "enemas until clear" to a young child, the nurse should select: a. Tap water. c. Oil retention. b. Normal saline. d. Fleet solution.

B (Normal saline. Isotonic solutions should be used in children. Saline is the solution of choice.)

An appropriate method for administering oral medications that are bitter to an infant or small child would be to mix them with: a. A bottle of formula or milk. b. Any food the child is going to eat. c. A small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream. d. Large amounts of water to dilute medication sufficiently.

C (A small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream. Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will make the medication more palatable to the child.)

Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. The most appropriate way to collect small amounts of urine for these tests is to: a. Apply a urine-collection bag to the perineal area. b. Tape a small medicine cup to the inside of the diaper. c. Aspirate urine from cotton balls inside the diaper with a syringe. d. Aspirate urine from a superabsorbent disposable diaper with a syringe.

C (Aspirate urine from cotton balls inside the diaper with a syringe. To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe.)

Several types of long-term central venous access devices are used. A benefit of using an implanted port (e.g., Port-a-cath) is that it: A. Is easy to use for self-administered infusions. B. Does not need to pierce the skin for access. C. Does not need to limit regular physical activity, including swimming. D. Cannot dislodge from the port, even if child plays with port site.

C (Does not need to limit regular physical activity, including swimming.)

In some genetically susceptible children, anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that, in addition to an increased temperature, an early sign of this disorder is which of the following? a. Apnea b. Bradycardia c. Muscle rigidity d. Decreased blood pressure

C (Early signs of malignant hyperthermia include tachycardia, increasing blood pressure, tachypnea, mottled skin, and muscle rigidity.)

Nursing considerations related to the administration of oxygen in an infant include to: a. Humidify the oxygen if the infant can tolerate it. b. Assess the infant to determine how much oxygen should be given. c. Ensure uninterrupted delivery of the appropriate oxygen concentration. d. Direct the oxygen flow so that it blows directly into the infant's face in a hood.

C (Ensure uninterrupted delivery of the appropriate oxygen concentration. Oxygen is a prescribed medication. It is the nurses' responsibility to ensure that the ordered concentration is delivered and the effects of therapy are monitored.)

The nurse must suction a child with a tracheostomy. Interventions should include: a. Encouraging the child to cough to raise the secretions before suctioning. b. Selecting a catheter with a diameter three-fourths as large as the diameter of the tracheostomy tube. c. Ensuring that each pass of the suction catheter take no longer than 5 seconds. d. Allowing the child to rest after every 5 times the suction catheter is passed.

C (Ensuring that each pass of the suction catheter take no longer than 5 seconds. Suctioning should require not longer than 5 seconds per pass. Otherwise the airway may be occluded for too long.)

Tepid water or sponge baths are indicated for hyperthermia in children. The nurse should do which of the following? a. Add isopropyl alcohol to the water. b. Direct a fan on the child in the bath. c. Stop the bath if the child begins to chill. d. Continue the bath for 5 minutes.

C (Environmental measures such as sponge baths can be used to reduce temperature if tolerated by the child and if they do not induce shivering. Shivering is the body's way of maintaining the elevated set point. Compensatory shivering increases metabolic requirements above those already caused by the fever.)

A neonate had corrective surgery 3 days ago for esophageal atresia. The nurse notices that after the child receives his gastrostomy feeding, there is often a backup of formula feeding into the tube. As a result, the nurse should: A. Position the child in a supine position after feedings. B. Position the child on his or her left side after feedings. C. Leave the gastrostomy tube open and suspended after feedings. D. Leave the gastrostomy tube clamped after feedings.

C (Leave the gastrostomy tube open and suspended after feedings.)

When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? a. Administering the medication with a syringe (without needle) placed along the side of the infant's tongue b. Administering the medication as rapidly as possible with the infant securely restrained c. Mixing the medication with the infant's regular formula or juice and administering by bottle d. Keeping the child upright with the nasal passages blocked for a minute after administration

C (Mixing the medication with the infant's regular formula or juice and administering by bottle.)

In some genetically susceptible children, anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that, in addition to an increased temperature, an early sign of this disorder is: a. Apnea. b. Bradycardia. c. Muscle rigidity. d. Decreased blood pressure.

C (Muscle rigidity.)

A nurse must do a venipuncture on a 6-year-old child. An important consideration in providing atraumatic care is to: a. Use an 18-gauge needle if possible. b. If not successful after four attempts, have another nurse try. c. Restrain the child only as needed to perform venipuncture safely. d. Show the child equipment to be used before procedure.

C (Restrain the child only as needed to perform venipuncture safely. Restrain child only as needed to perform the procedure safely- use therapeutic hugging.)

The emergency department nurse is cleaning multiple facial abrasions on 9-year-old Mike. His mother is present. He is crying and screaming loudly. The nurse should: a. Ask him to be quieter. b. Have his mother tell him to relax. c. Tell him it is okay to cry and scream. d. Suggest that he talk to his mother instead of crying.

C (Tell him it is okay to cry and scream.)

The emergency department nurse is cleaning multiple facial abrasions on 9-year-old Mike. His mother is present. He is crying and screaming loudly. The nurse should do which of the following? a. Ask him to be quieter. b. Have his mother tell him to relax. c. Tell him it is okay to cry and scream. d. Suggest he talk to his mother instead of crying.

C (The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know it is all right to cry.)

What should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of 7 years or older is required for a consent to be considered "informed."

C (The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. In special circumstances such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. A mental age of 7 years is too young for consent to be informed.)

Which of the following should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of 7 years or older is required for a consent to be considered "informed."

C (The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure.)

A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). The nurse should explain that antipyretics: a. may cause malignant hyperthermia. b. may cause febrile seizures. c. are of no value in treating hyperthermia. d. are of limited value in treating hyperthermia.

C (Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead.)

What nursing action is appropriate for specimen collection? a. Follow sterile technique for specimen collection. b. Sterile gloves are worn if the nurse plans to touch the specimen. c. Use Standard Precautions when handling body fluids. d. Avoid wearing gloves in front of the child and family.

C (Use Standard Precautions when handling body fluids.)

The nurse is caring for an unconscious child. Skin care should include: a. Avoiding use of pressure reduction on the bed. b. Massaging reddened bony prominences to prevent deep tissue damage. c. Using draw sheet to move child in bed to reduce friction and shearing injuries. d. Avoiding rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

C (Using draw sheet to move child in bed to reduce friction and shearing injuries.)

The nurse is preparing a plan to teach a mother how to administer 1½ teaspoons of medicine to her 6-month-old child. The nurse should recommend using: A. A household measuring spoon. B. A regular silverware teaspoon. C. A paper cup measure in 5-ml increments. D. A plastic syringe (without needle) calibrated in milliliters.

D (A plastic syringe (without needle) calibrated in milliliters.)

The nurse approaches a group of school-age patients to administer medication to Sam Hart. To identify the correct child, the nurse should: a. Ask the group, "Who is Sam Hart?" b. Call out to the group, "Sam Hart?" c. Ask each child, "What's your name?" d. Check the patient's identification name band.

D (Check the patient's identification name band. The child must be correctly identified before the administration of any medication. Children are not totally reliable in giving correct names on request- identification bracelet should always be checked.)

An appropriate intervention to encourage food and fluid intake in a hospitalized child is to: a. Force child to eat and drink to combat caloric losses. b. Discourage participation in noneating activities until caloric intake is sufficient. c. Administer large quantities of flavored fluids at frequent intervals and during meals. d. Give high-quality foods and snacks whenever child expresses hunger.

D (Give high-quality foods and snacks whenever child expresses hunger.)

Standard Precautions for infection control include that: A. Gloves are worn any time a patient is touched. B. Needles are capped immediately after use and disposed of in a special container. C. Gloves are worn to change diapers when there are loose or explosive stools. D. Masks are needed only when caring for patients with airborne infections.

D (Masks are needed only when caring for patients with airborne infections.)

When caring for a child with an intravenous infusion, the nurse should: a. Use a macrodropper to facilitate reaching the prescribed flow rate. b. Avoid restraining the child to prevent undue emotional stress. c. Change the insertion site every 24 hours. d. Observe the insertion site frequently for signs of infiltration.

D (Observe the insertion site frequently for signs of infiltration. The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time, set the infusion rate, and monitor the apparatus frequently (at least every 1 to 2 hours) to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop.)

The nurse needs to take the blood pressure of a preschool boy for the first time. Which action would be BEST in gaining his cooperation? A. Taking his blood pressure when a parent is there to comfort him. B. Telling him that this procedure will help him get well faster. C. Explaining to him how the blood flows through the arm and why the blood pressure is important. D. Permitting him to handle equipment and see the dial move before putting the cuff in place.

D (Permitting him to handle equipment and see the dial move before putting the cuff in place.)

When administering a gavage feeding to a school-age child, the nurse should: a. Lubricate the tip of the feeding tube with Vaseline to facilitate passage. b. Check the placement of the tube by inserting 20 mL of sterile water. c. Administer feedings over 5 to 10 minutes. d. Position the child on the right side after administering the feeding.

D (Position the child on the right side after administering the feeding. Position the child with the head elevated about 30 degrees and on the right side or abdomen for at least 1 hour. This is in the same manner as after any infant feeding to minimize the possibility of regurgitation and aspiration.)

The nurse is doing preoperative teaching with a child and his parents. The parents say that he is "dreading the shot" for premedication. The nurse's response should be based on the knowledge that: A. Preanesthetic medication can only be given intramuscularly. B. In children the intramuscular route is safer than the intravenous (IV) route. C. The child will have no memory of the injection because of amnesia. D. Preanesthetic medication should be "atraumatic," using oral, existing intravenous, or rectal routes.

D (Preanesthetic medication should be "atraumatic," using oral, existing intravenous, or rectal routes.)

An 8-month-old infant is restrained to prevent interference with the intravenous infusion. The nurse should: a. Remove the restraints once a day to allow movement. b. Keep the restraints on constantly. c. Keep the restraints secure so the infant remains supine. d. Remove the restraints whenever possible.

D (Remove the restraints whenever possible. The nurse should remove the restraints whenever possible. When parents or staff are present, the restraints can be removed and the IV site protected.)

An appropriate intervention to encourage food and fluid intake in a hospitalized child is which of the following? a. Force child to eat and drink to combat caloric losses. b. Discourage participation in noneating activities until caloric intake is sufficient. c. Administer large quantities of flavored fluids at frequent intervals and during meals. d. Give high-quality foods and snacks whenever child expresses hunger.

D (Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and cheese should be available.)

The nurse is caring for an infant with a tracheostomy when accidental decannulation occurs. The nurse is unable to reinsert the tube. What should be the NEXT action by the nurse? A. Notifying the surgeon B. Performing oral intubation C. Trying to insert a larger-size tube D. Trying to insert smaller-size tube

D (Trying to insert smaller-size tube.)

Which is the preferred site for intramuscular injections in infants? a. Deltoid b. Dorsogluteal c. Rectus femoris d. Vastus lateralis

D (Vastus lateralis)

The nurse must do a heel stick on an ill neonate to obtain a blood sample. Which procedure is recommended to facilitate this? a. Apply cool, moist compresses. b. Apply a tourniquet to the ankle. c. Elevate the foot for 5 minutes. d. Wrap foot in a warm washcloth.

D (Wrap foot in a warm washcloth. Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10 minutes to dilate the blood vessels in the area.)

The nurse is preparing for the admission of an infant who will have several procedures performed. In which situation is informed consent required (Select all that apply)? a. Catheterized urine collection b. Intravenous (IV) line insertion c. Oxygen administration d. Lumbar puncture e. Computed tomography (CT) scan with contrast

D, E (Lumbar puncture Computed tomography (CT) scan with contrast)